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Please fill in all you can
Be sure to put SOMETHING where you see the (*)

      I assure you that none of your personal information on this survey  
    will be made public. We gather such information ONLY to determine
    who our audience is. Eventually, when I get more programming done,
    we will be creating chat groups, travel groups, "pet lover" groups
    and the like. At that time, you may choose (or not) to share
    information with our members.

* Your First Name
Middle Name or Initial
* Last Name
* Occupation
Occupation - if not Listed
School or Employer
Your Street Address
* City * State * Zip
* Country
* Birth Date
Year Month Day
Primary Phone Number
Other Phone
Primary FAX
Second FAX
* e-mail Address
* InterNet Service Provider
* Marital Status
Not Am Happily EX'ed
* Kids at home
Zip 1-3 4-6 Catholic
* Shoe Size
Less 5-9 More Hippy
* Color of Hair
Light Dark Grey (ish) Female
Ethnicity (Race)
Asian
Black
Hispanic
White
Heinz 57 (American)
Other Other
Primary Language
English
French
Spanish
Southern
Japaneese
Other Other
Education
Blonde 12-15 BA/BS More
Household Yearly Income
Less $25-$50k $51-$70k More
Usually On the WEB
Day Evening Night Live There
Usually On the Web
Less 1-3 hrs 3-5 hrs More
Please check the boxes that apply to your Web Likes
Research Travel Educational Games Trash

Other
Please check the boxes for the stuff you have
Digital Camera Video / Mike Girlfriend Boyfriend Fleas

Other
Please check the boxes for the stuff you WANT
Digital Camera Video / Mike Girlfriend Boyfriend Dog

Other
Please type in anything you want (or not!)
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